COVID-19 Questionnaire

COVID-19 QUESTIONNAIRE

If you are unable to answer the following questions to our satisfaction, you will not be able to travel with Pixelchrome Photo Tours.
If any answers change between when you fill out this document and 72 hours before you arrive at the tour starting destination you must contact me immediately as we may no longer be able to accommodate you. We will issue you with a FULL REFUND.
We take the health and safety of everyone who comes on a Pixelchrome Photo Tours adventure very seriously, thank you for your cooperation
Please read each question carefully.

Personal information

* Indicates required field

Name as it appears on your Passport *

Zip Code *

Phone Number *

Covid-19 Screening
Have you experienced any of the following symptoms that are not associated with any underlying medical condition or medication use.

Select One *

Covid-19 Contact
Please enter the estimated date of any close contact that you have had to a confirmed case of COVID-19. Close contact is defined as being within approximately 6 feet (2 meters) of a confirmed COVID-19 case for at least 15 minutes. Please select "Not Applicable" if you have not been exposed to your knowledge.

MM/DD/YYYY *

Please select if not applicable *

Not Applicable

Family Cases of Covid-19
Enter the date of the most recent positive Covid-19 test received by someone in your household (not including yourself). Please select "Not Applicable" if no one in your household has ever tested positive for COVID-19.

MM/DD/YYYY *

Please select if not applicable *

Not Applicable

Covid-19 Testing
Enter the date of your most recent COVID-19 test.

MM/DD/YYYY *

Please select if not applicable *

Not Applicable

You will be required to show that you have had a Covid-19 test with 72 hours of arriving at the starting point of our tour.

CVS are conducting free tests in many areas. Check the following link to see if there is a location in your area.

Survey results
If your survey results indicate you are eligible, do you plan to attend the photo tour?

Select One *

Declaration
I certify that I have answered truthfully to the best of my ability.

Please answer and then fill in your digital signature *

Yes

Digital Signature *

First

Last

To submit your Covid-19 Screening Information, please click once on the button below.

NB. it may take up to a minute to send. Please do not close out of the browser
until you receive a confirmation

Submit Covid-19 Screening Form

COVID-19 QUESTIONNAIRE

COVID-19 QUESTIONNAIRE

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